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Benefit Counselor Application
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Legal Name
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National Producer #
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Resident State License #
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Exp date
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Do you have an Active Long Term Care Certification (LTC)?
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Address
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Gender
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Phone Number
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Personal Email
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Case Preference (please select one)
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Travel Only
Virtual Only
Travel or Virtual
Local/Virtual
Do you speak additional languages (fluently)
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Yes
No
(Please list them)
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States that you are actively licensed in (Check all that apply)
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Are you willing to submit to a background check?
*
Yes
No
Do you have access to up to $1,000 in credit?
*
Yes
No
What Enrollment firms have you worked with?
*
Which Enrollment Systems have you used?
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ADP
Bswift
Employee Navigator
Plansource
PeopleSoft
Selerix
Ultipro
Workday
Which worksite carriers have you represented?
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Aflac
Allstate
Boston Mutual
Colonial
Chubb
Guardian
Humana
The Standard
Reliant S
Voya
Lincoln Financial Group
Metlife
Transamerica
Trustmark
Unum
How did you learn about 九色?
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Website
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Referral
Referral Name
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Nearest major airport?
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